Idealism can be the enemy of culture change in the NHS

'It is absolutely right we have a preeminent safety culture both in what we do and what we don't do' says Dean Royles. Photograph: Ulrich Baumgarten/Getty Images

As I get out and about in the NHS, I'm taken with the gap between the pride staff and managers feel about the progress they are making and the care they are able to give most of the time, and the seemingly endless press criticism of the NHS. Report after report highlights the overwhelmingly positive contribution of the NHS but that seems to get lost in the coverage. And if you highlight this gap you can be presented as naive, as not getting the change that is needed.

All the recent coverage about the quality of NHS care from Francis, to Keogh to Berwick and the reports expected by Anne Clwyd on complaints have helped ensure that everyone agrees on the solution to this NHS problem. It's a surprising answer; it's not funding, it's not structure and it's not integration of services. All of those, it seems, are comparatively easy to fix. Almost everyone now agrees that it's the NHS culture.

And I would largely agree. We certainly need culture change, both to help embrace the learning from these important reports and because the context we are now in follows a massive reorganisation of the NHS.

Whether you agree with the changes or not, we know from endless reorganisations that these structural changes don't change culture. It is also clear that future funding settlements in an age of austerity will impact on how services are delivered and the choices that are made. This too will require significant culture change. The increasing debate around the need for more and better seven day care is a case in point.

But I am worried. Blaming 'the culture' has become too easy. Funding, structure and staffing don't seem to get a look in. Change the culture and everything else follows. Really?

Every time there is a problem - a staffing issue, a complaint, a quality concern, a bullying allegation, a system failure, or a whistleblower -the shout goes out, "That's why we need to change the culture". It's as though culture change, which is often ill defined, will solve the ails of the NHS and nothing will ever go wrong. Furthermore, it seems the culture we currently have is responsible for the failings in the NHS, but that the millions of people receiving exceptional care and treatment every week receive it by chance.

An idealistic view that 'culture change' will solve all the problems in the NHS will leave us all disappointed. Worse than that, it will prevent progress and lead to more blame. Let's not confuse culture (expressed as behaviours expected in a given environment) with cult (expressed as behaviours demanded by the environment). The latter will lead to inevitable destruction.

But it works in other industries, I hear you say. Take the aircraft industry. Their safety culture means that if it's not safe to fly, the planes don't take off. But it doesn't prevent all accidents does it? And there is something else. Context. The context of the NHS is important when seeking solutions to cultural change.

If a plane doesn't take off because of a crew shortage or a technical problem, we all get disappointed and upset by the inconvenience to our holiday or business plans — yet that's precisely what I would want if I were on the operating table. But is that the same in A&E or maternity or health visiting where the risk of closing may have equal or worse consequences than proceeding with caution? It is absolutely right we have a preeminent safety culture both in what we do and what we don't do. Let's get the risk management issues bang-on for the particular context and service we are in.

So let's continue with our culture change. Let's look at our systems to see how we can strengthen them. Let's challenge funding mechanisms. Let's look at our leadership programmes to see how we can develop. Let's be more open and involve staff and patients much better. Let's build and develop organisations that support our staff to deliver great care. Let's have an aspiration for a safer, more transparent NHS that is able to make changes with the patient at its heart.

But please don't allow the idealism of culture change to distort the complex interrelated managerial and clinical issues that we need to address, or we are bound to be disappointed.

Dean Royles is chief executive of NHS Employers

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